Journal of Public Health Advance Access published October 1, 2014

Journal of Public Health | pp. 1 7 | doi:10.1093/pubmed/fdu069

The development of a framework to integrate evidence

into a national injury prevention strategy
Andrea Chambers1, Sarah A. Richmond2, Louise Logan3, Colin Macarthur2,4,
Cameron A. Mustard1,5
1

Institute for Work and Health, 481 University Ave., Toronto, ON, Canada M5G 2E9
Child Health Evaluative Sciences, Hospital for Sick Children, Research Institute, 686 Bay St., Toronto, ON, Canada M5G 0A4
3
Parachute, 150 Eglinton East, Suite 300, Toronto, ON, Canada M4P 1E8
4
Department of Pediatrics, University of Toronto, 555 University Ave., Toronto, ON, Canada M5G 1X8
5
Dalla Lana School of Public Health, University of Toronto, 481 University Ave., Toronto, ON, Canada M5G 2E9
Address correspondence to Andrea Chambers, E-mail: achambers@iwh.on.ca
2

A B S T R AC T
Background Injury is the leading cause of death from birth to age 34 in Canada (Statistics Canada, 2008). In 2013, a national injury prevention
organization in Canada initiated a research-practitioner collaboration to establish a framework for incorporating evidence in the organizations
decision-making. In this study, we outline the development process and provide an overview of the framework.
Methods The process of development of the evidence-synthesis framework included consultation with national and international injury
prevention experts, a review of the research literature to identify existing models for incorporating research evidence into public health practice
and extensive interactions with the organizations leadership and staff.
Results A framework emphasizing four types of research evidence was recommended: (i) epidemiologic evidence describing the burden and
cause of injury, (ii) evidence concerning the effectiveness of interventions, (iii) evidence on effective methods for implementing promising
interventions at a population level, and (iv) evidence and theory from the behavioral sciences. Through the evidence-synthesis process the
framework prioritizes highly synthesized evidence-based strategies and draws attention to important research gaps.
Conclusions This study describes a novel opportunity to operationalize an organizations commitment to integrate evidence into practice. The
framework provides guidance on how to use evidence strategically to maximize the potential impact of prevention efforts. Opportunities for
further evaluation and dissemination are discussed.
Keywords action research, models, public health

Background
Injury is the leading cause of death from birth to age 34 years
in Canada,1 and leaders in the eld of injury prevention have
called for a national strategy. In 2013, Parachute, an injury prevention NGO in Canada initiated a research-practitioner collaboration to establish a framework for incorporating research
evidence into the organizations strategic planning and
program decision-making. In this study, we outline the development process and provide an overview of an evidencesynthesis framework.
Parachute is a national injury prevention charity in Canada
that was created in July 2012 through the amalgamation of
four organizations that had over 80 years of collective

experience in injury prevention. The establishment of

Parachute created a unique opportunity to embed evidenceinformed decision-making into the organization. This commitment was explicit in the organizations inaugural Strategic
Plan. Parachute then recruited two early-career public health
scientists to develop an evidence-synthesis framework that

Andrea Chambers, Post-doctoral Fellow

Sarah A. Richmond, Post-doctoral Fellow
Louise Logan, Parachute CEO
Colin Macarthur, Associate Chief of Clinical Research
Cameron A. Mustard, President and Senior Scientist

# The Author 2014. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

J O U R NA L O F P U B L IC H E A LT H

would guide the organizations efforts to reduce the burden of

preventable injury in Canada.
The process of development of the evidence-synthesis
framework included consultation with national and international injury prevention experts, a review of the literature to
identify existing models for incorporating research evidence
within an injury prevention strategy and extensive interactions
with Parachutes leadership and staff. A framework emphasizing four types of research evidence was recommended:
(i) epidemiologic evidence describing the burden and causes
of injury, (ii) evidence on the effectiveness of interventions,
(iii) evidence on effective methods for implementing interventions at a population level and (iv) evidence and theory from
the behavioral sciences on the mechanisms behind intervention components that modify behavioral objectives. The

framework prioritizes evidence-based strategies and also

draws attention to important research gaps. We introduce the
elements of the framework in Fig. 1. The objective of this
study is to describe the setting and processes that inuenced
the development of this innovative framework.

The process
Parachutes Strategic Plan has set a 3-year milestone of a 25%
reduction in the frequency of injury in Canada. The evidencesynthesis framework was developed to align with six areas of
focus to achieve this goal: (i) strategy development, (ii) prevention programming, (iii) raising awareness, (iv) inuencing
public policy, (v) inuencing research priorities and (vi)
strengthening data for monitoring injury trends. The

Type I

Epidemiological assessment
Ongoing summary of injury indicators
List of evidence-based risk and
protective factors

Type II

Existing evidence based

intervention options
Review of reviews to identify
intervention options with sufficient
levels of evidence
List of evidence-based options by risk/
protective factors

Gaps & promissing interventions

New opportunities

Promising interventions or new ideas

that target high burden and/or
increasing severity injury problems and
risk factors where there are no options
with sufficient evidence

Future collaborations and investment in

priority injury areas or new ideas that
currently do not have strong or sufficient
evidence of ineffectiveness or
unintended consequences

Priority setting
Multi criteria decision analysis

Type III/IV

List of prioritized evidence-based

intervention options

Solution mobilization

Evaluation

Development of the program theory,

type IV evidence

Routine monitoring & evaluation of internal

outputs, reach, and initial and intermediate
outcomes

Collection and synthesis of type III

evidence
Review principles and evidence for best
practices in adaption, implementation,
dissemination and sustainability

Establish partnerships to carry out evaluations

looking at long-term outcomes
Disseminate evaluation resources

Fig. 1 Evidence-synthesis framework for injury prevention practice.

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following sections highlight the inuence of expert consultations, literature review and staff engagement in the development of the framework.
Consultations with key informants

We conducted interviews with 18 key informants from academic

and non-academic injury prevention organizations within
Canada (including the British Columbia Research and
Prevention Unit, the Atlantic Collaborative in Injury Prevention,
the Alberta Centre for Injury Control and Research, the Public
Health Agency of Canada and the New Brunswick Trauma
Program) and internationally (the Center for Disease Control
and Prevention and the European Child Safety Alliance) to learn
about existing frameworks that integrate evidence into decisionmaking processes. We also reviewed existing national and international injury prevention strategies. Two types of tools were
identied in our networking process: frameworks that guide a
priority setting process to integrate different types of evidence to
select injury problems for strategic planning purposes and guidance on how to make decisions around the level of evidence for
prevention strategies. Prioritization strategies involved selecting
criteria making comparison across options; applying weights to
those criteria and scoring each option based on performance.
From the networking process we learned that existing strategies
to integrate evidence into decision-making processes did not
support the full spectrum of prevention activities. Furthermore,
some organizations reported that it had been difcult to sustain
evidence-based decision-making processes over time suggesting
challenges in adoption, feasibility, and sustainability.
The key informant interviews reinforced the need for a
new framework to synthesize evidence across a range of
injury prevention activities. The two main strategies that
organizations were using were perceived to be important for
inclusion in the evidence-synthesis framework; however, there
was recognition that processes would have to be feasible and
sustainable overtime.
Review of existing models for public health
planning

A broad scoping review of the literature was conducted to

identify models, frameworks or general approaches to integrate evidence into decision-making processes across the following themes: priority setting, program design, evaluation,
dissemination and implementation. Existing models that were
identied were evaluated according to the level of exibility of
the model constructs. We also determined whether existing
frameworks or models were designed specically for decisionmaking at the individual, organizational, community, or
systems level, whether elements of critical appraisal were

included, whether the tool came with any resources and

whether the model was associated with an existing theory or
related framework. Our goal was to identify an existing comprehensive framework that would provide guidance on the integration of evidence across the full spectrum of prevention
activities carried out by Parachute.
Four public health frameworks were identied that met the
requirements of our search and helped frame an initial conception of the evidence-synthesis framework. These included
the public health approach,2 the evidence-informed public
health movement,3 the precede proceed model4 and the
RAND getting to outcomes model.5 These frameworks
were evaluated for their alignment with Parachutes mandate
and goals. Gaps and limitations inherent in the use of these
existing frameworks provided the foundation for developing
the evidence-synthesis framework introduced in this study.
For each of the four public health frameworks, Table 1 highlights specic strengths, an example of a previous application
in injury prevention and specic elements that informed
Parachutes evidence-synthesis framework.
The public health approach includes ve functional steps: surveillance, research on risk and protective factors, research on
interventions, program and policy implementation, and monitoring and evaluation.2 The approach provided limited details
on how to operationalize each of these steps. Furthermore,
additional guidance was needed on the synthesis of evidence
to support the mobilization of strategies and to support the
strategic use of evidence for priority setting.
The evidence-based public health movement also inuenced the
evidence-synthesis framework.3 While the movement has not
produced an evidence-synthesis model, there are a number
of principles within this movement that were perceived to be
instrumental for Parachute to adopt. To align with the
evidence-informed public health movement one needs to
consider the quality of evidence, levels of evidence and adopt
a more systematic approach to gathering and synthesizing evidence for practice.
The PRECEDEPROCEED model is a widely known
model in health promotion and public health program planning.4 The model describes a series of phases in the planning,
implementation and evaluation of programs and also incorporates considerations around priority setting. There was a discrepancy in the alignment between this model and the scope of
Parachutes prevention work. The PRECEDEPROCEED
model is designed to guide the user through a process to
develop a new prevention program. As Parachute is faced with
competing opportunities we saw value in focusing on the identication of existing evidence-based strategies for mobilization.
The RAND Getting to Outcomes model was developed as a
guide for public health practitioners.5 It includes 10 steps

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Table 1 Overview of public health frameworks that influenced Parachutes evidence-synthesis framework
Model/approach

Strengths

Applications in injury prevention

Application to the framework

Public health

Draws attention to the importance of

The Center for Disease Control and

All steps of the public health approach have

approach

establishing evidence on the underlying

Prevention has used the public health

been integrated into the framework

determinants of injury risk.

approach to identify important efforts

(surveillance, research on risk and protective

Describes a broad range of important

needed to reduce the impact of traumatic

factors, prevention strategies and

public health prevention activities

brain injuries in the USA6

implementation best practices; and

ongoing evaluation and monitoring

Evidence-based

Emphasizes the systematic identification The evidence-based public health

public health

and critical evaluation of the quality of

movement has been applied to support

framework provided the foundation of

movement

different types of evidence that informs

recommendations for the U.S. Military on

systematic use of evidence including:

public health practice

the effectiveness of injury prevention

integration of different types of evidence,

efforts2

critical appraisal and evaluating the state of

The core components integrated into the

the evidence
PRECEDE

Theoretically grounded and

The PRECEDE PROCEED model has been

Core components integrated into the

PROCEED

comprehensive in providing guidance in

applied to support planning of child

framework included epidemiological

the areas of planning, implementation

pedestrian injury prevention programs7

assessment and identification of risk and

and evaluation.

protective factors. The administrative and

One of the most widely known program

policy assessment phase informed the

planning models with a number of

priority setting stage. The connections made

applications

between the PRECEDE planning steps and

PROCEED evaluative activities informed the
evaluation section of the evidence-synthesis
framework

RAND Getting to

Theoretically grounded model that

The Getting to Outcomes framework has

The RAND model informed the inclusion of

Outcomes

provides guidance across the full

been used for prevention strategy

guidance around mobilization of effective

spectrum of prevention activities. Has

targeting underage drinking8

interventions including considerations

been described as a user-friendly

around the adaptation of evidence-based

process incorporating a number of tools

strategies to align with the needs of a target

to support implementation

population

that incorporate planning, implementation and evaluation of

prevention programs. Where the PRECEDE PROCEED
model is focused on the design of novel programs, the
RAND model emphasizes the identication of existing programs and best practices worth copying. For an organization
with competing opportunities and the opportunity to mobilize prevention strategies nationally, a focus on the identication and appraisal of programs and practices with established
effectiveness was recognized as an important component of
the Parachute evidence-synthesis framework. The RAND
model also emphasized the adaptation of evidence-based
strategies to meet the needs of a target population. This
model provided signicant utility in dening the scope of the
evidence-synthesis framework; however, through our interactions with the organization we identied the need to rethink
the placement of priority setting. The RAND model recommends that one dene their goals, target population and
outcomes prior to identifying existing programs and best

practices worth implementing. The evidence-synthesis framework described in this study places priority setting after completing a high level synthesis of risk and protective factors and
evidence-based strategies for a dened injury problem. The
value of this approach will be described in the next section.
Engagement with Parachute leadership and staff

An interactive engagement with Parachute leadership and

staff, using the principles of appreciate inquiry,9 informed the
modication of existing public health models to dene an
evidence-synthesis framework aligned with Parachutes
mandate and goals. We used a collective discovery process
( p. 2) to assess the applicability of the framework, and how
the framework would exist within the existing organizational
structure.9 At the onset of the framework development
process, opportunities for collaboration, interviewing, discussions and presentations about the project and process were
carried out with staff across the organizational hierarchy.

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From early interactions with Parachute leadership and staff,

it was recognized that priority setting would be an important
component of the evidence-synthesis framework. Priority
setting is not always consistently integrated within public
health models. Among those models that do outline a priority
setting stage, it tends to be placed early in the planning
process. For example, the RAND model implicitly recommends a priority setting strategy that starts with dening the
target population. The PRECEDE PROCEED model
recommends prioritization of risk and protective factors,
prior to the behavioral and environmental assessment phase.
To align with the organizations goal to mobilize a number
of evidence-based strategies with high-impact potential, we
saw value in delaying the priority setting process until information was collected on a wide range of available evidencebased strategies. The Parachute evidence-synthesis framework
places priority setting at the core of the framework. The
Parachute framework ips the priority setting process upside
down, rst synthesizing available evidence on intervention
options before specifying the target populations.
For an organization with competing opportunities and an
ambitious prevention goal, we saw value in placing more emphasis on the impact of proven, effective interventions. The
value would come from identifying evidence-based strategies
with sufcient levels of evidence (i.e. what we know works)
and prioritizing intervention option based on impact potential
in addition to other important considerations related to feasibility and implementation complexity. This strategy provides
an opportunity to identify proven interventions with highimpact potential for active mobilization across Canada.
The interviews with staff were used to acquire a detailed
understanding of how the organization and individuals within
the organization currently identied and used information
and what was expected from the development of an evidencesynthesis framework.
Another unique component of the evidence-synthesis
framework that was directly inuenced by having an integrated and reexive exchange with the organization was to
integrate a process to identify research gaps and mobilize
opportunities to evaluate promising strategies. One of the
concerns expressed by Parachute staff was missing opportunities to support innovative ideas in the community by excluding promising strategies that target emergent and
important risk and protective factors. It was recognized that
there was an opportunity in the existing evidence-synthesis
process to identify and draw attention to research gaps.
Promising strategies that have limited evidence of effectiveness yet target important risk or protective factors should be
acknowledged and receive support for further attention and
evaluation.

The evidence-synthesis framework

The evidence-synthesis framework model is outlined in
Fig. 1. Detailed guidance on the processes, resources and
tools to operationalize the evidence-synthesis framework is
outlined in an evidence-synthesis manual. The framework
functions within a context of on-going research exchange,
using a participatory approach that involves stakeholders
across the spectrum of prevention activities. These members
include knowledge translation coordinators, practitioners,
researchers and community members, relying on input and
collaboration throughout the process. The framework integrates four types of evidence, triangulated to provide insight
from both a quantitative and qualitative perspective.3 The use
of the term type of evidence is not to be aligned with levels
of evidence, it is specic to the type of information collected.
Type I evidence is reviewed at the epidemiological assessment
phase and refers to information on incidence and prevalence
of injury problems and risk and protective factors as well as
the size and strength of associations between risk and protective factors and injury outcomes. Type II evidence is assessed
at the next stage of the model referring to information on the
relative effectiveness of interventions. Type III evidence is
assessed at a stage termed strategy mobilization: an evidence-synthesis stage that serves to collect information that
will promote delity, adaptation, successful implementation
and sustainability of evidence-based strategies. A fourth type
of evidence is also proposed (Type IV evidence) to guide the
development of the program theory at the solution mobilization stage. Evidence and theory from the behavioral sciences
literature can support the identication of the mechanisms
behind intervention components that modify behavioral
objectives supporting the design of prevention strategies. The
operationalization of the use of all four types of evidence
highlighted in this model includes a process of on-going evidence gathering, synthesis, critical appraisal, prioritization,
mobilization and evaluation.
There are other important features of the framework. To
optimize the successful impact of evidence-based strategies,
the framework recommends that priority setting should be
conducted following a review of evidence-based intervention
options. This contrasts with the conventional approach of
setting priorities following an assessment of burden. Because
burden does not always correlate with availability of highimpact evidence-based intervention options, a priority-setting
process that emphasizes burden and risk factors may miss opportunities to invest in evidence-based program options that
have high impact potential.
The framework recommends that priority-setting processes
draw on a form of multi-criteria decision analysis10 to

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generate a list of prioritized evidence-based strategies for solution mobilization. Intervention options can be compared
across a number of important criteria including existing opportunities, impact potential, cost-effectiveness and equity.
This is a process that can take into account the goals, principles, values and resources of an organization.
A second important feature of the evidence-synthesis framework is the acknowledgement of evidence gaps. There is a need
for a strategy to draw attention to the types of information
needed in injury prevention practice. While the process
described in the framework prioritizes evidence, it leaves room
for new and promising opportunities to address important risk
and protective factors where there is an absence of evidencebased intervention options. A number of organizations have
strived to outline proven evidence-based strategies. The
evidence-synthesis framework is designed to expand this list
and collect information that can be used to successfully mobilize evidence-based injury prevention strategies across Canada.
It is recommended that for each prioritized evidence-based
strategy, information should be provided on the burden of the
injury problem and the underlying risk and protective factors,
evidence on the overall effectiveness and cost-effectiveness of
the strategy, and information to inform best practices around
adaptation, implementation, delity and sustainability.
The nal component of the evidence-framework is evaluation. The evaluation directions emphasized in the framework
were meant to align with the organizations focus on drawing
attention to evidence-based strategies and the burden of
injury in Canada (rather than program design and implementation). The levels of uptake and application of evidencebased strategies that have been mobilized can directly inform
the success of the organizations prevention efforts. To align
with efforts to mobilize Canadians to adopt solutions, there is
a focus on providing evaluation resources to communities
and organizations.

Facilitators of the development process

There are important features of the organizational environment that supported the development and implementation
of an evidence-synthesis framework. Leadership has been
recognized as an important condition that can support
evidence-based decision-making by inuencing the organizational culture and use of nite resources.3 As outlined in
the introduction, to support the amalgamation, there was an
attempt to recruit leadership that was committed to an
evidence-based approach. The transition was guided by a
leader who had previous experience successfully integrating
evidence into organizational processes with measureable
outcomes.

One of the unique conditions that facilitated the integration

of evidence into the decision-making structure of the organization was through a strategic commitment to be evidenceinformed and a plan to operationalize the organizations
commitment. One of the core principles outlined in the organizations rst Strategic Plan was to adopt an evidence-based
approach to setting priorities, designing implementable and
scalable solutions and evaluating impact. Parachute was
established from four legacy organizations that had strong
connections to the research community. It was evident that
this culture of research-practitioner collaboration was carried
forward in the new organization. Establishing the evidenceframework early during the amalgamation provided an opportunity to build on the scope and activities of the organization
and develop the capacity to support an evidence-synthesis
framework.
As alluded to in the description of the setting, there was
fertile ground for this project. Program staff were aware that a
commitment to be evidence-informed would be challenging
and overwhelming to follow without a process to actually dene
what it meant to be evidence-informed in practice. A shared optimism and support for the research-practitioner collaboration
was also inuenced by the staff s perspective towards the value
and utility of an evidence-informed approach. This commitment was viewed by staff as an opportunity to enhance the credibility of the organization. Staff felt more condent about
meeting the organizations goal to reduce injuries across Canada
as they could see the connection between the strategies they
would support and the prevention goals set by the organization.

Discussion
Main findings of this study

The Parachute evidence-synthesis framework is an example of

how to pull research in to inform decision-making. The
evidence-synthesis framework has been inuenced by established public health models. The Parachute framework gives
priority to the identication and selection of intervention strategies that have strong evidence of effectiveness. The structures
and products of the process outlined in the framework help
bring attention to research gaps in available evidence-based
strategies for well-dened risk and protective factors.
What is already known on this topic

Knowledge translation models have emphasized that

researchers need to actively push research out to users and
users need to actively pull in research to inform decisionmaking in public health practice.11 There have been a number
of studies that have drawn attention to the barriers in the integration of evidence into practice.12 15

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What this study adds

The framework introduced in this study outlines a process

that can be used to bridge the research-to-practice gap. The
evidence-synthesis process provides an opportunity to use
evidence in a strategic way to maximize the impact potential
of national prevention strategies and bring attention to the
need for more research to address gaps in our understanding
of risk and protective factors, interventions and implementation best practices.
The evidence-synthesis framework is currently being pilot
tested to prioritize evidence-based interventions for the prevention of motor vehicle injury in Canada. The success of the
framework will be measured not only by its potential to mobilize evidence-based injury prevention strategies across
Canada but also by its sustainability in the processes and priorities of the organization.

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